Sleep and Adhd The Link between Parent and Child Sleep Disturbances in Children with Attention Deficit Hyperactivity Disorder Dr. Martin Efron The Child Psychiatry Unit, Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel

Introduction Background history The awareness of a link between sleep disturbances and attention-deficit/hyperactivity disorder (ADHD) is not novel at all. In 1957, Laufer and Denhoff wrote: “Generally the parents of hyperkinetic children are so desperate over the night problems that the daytime ones pale in significance” Laufer MW, Denhoff E. Hyperkinetic behavior syndrome in children. J Pediatr 1957;50:463–74

Introduction Attention Deficit/Hyperactivity Disorder (ADHD), is characterized by a pattern of inattentive, hyperactive and impulsive behaviors. Symptoms of ADHD have been associated with a broad range of negative outcomes, including social, academic, and emotional difficulties One of the most prominent features of childhood ADHD is sleep problems, with prevalence rates from 25% to as high as 80% Behavior sleep problems (i.e., bedtime resistance, multiple awakenings, sleep onset latency) and more “physiological” based sleep problems (e.g., obstructive sleep apnea, restless legs syndrome) are commonly observed among children with ADHD

Introduction The impact of disrupted sleep on behavioral, cognitive, and emotional functioning in healthy children has been the focus of many studies in the past decade. : Insufficient or poor sleep quality is known to be associated with -mood dysregulation -lower neuro­cognitive performances - decreased focused attention - difficulty modulating impulses Moreover, short sleep duration has been reported to be associated with ADHD­like behavior and poor cognitive and academic achievements in healthy children Thus, in healthy children, the manifestations of sleep problems may "mimic" ADHD symptomatology

IS THE SLEEP OF CHILDREN WITH ADHD DISTURBED? Children with ADHD commonly experience sleep problems such as: bedtime resistance more difficulty falling asleep more nighttime awakenings greater difficulty waking up in the morning more daytime sleepiness. increased sleep-onset latency more stage shifts per hour lower sleep efficiency on polysomnography shorter total sleep time. 

Comorbidity (anxiety and mood disorders) Neuropsychological deficits ADHD Sleep problems Comorbidity (anxiety and mood disorders) Neuropsychological deficits

Parents Parents of children suffering from ADHD may also be negatively affected by  their children's sleep problems.  These parents may experience more parenting stress  and poorer mental health (including depression, anxiety and stress) Parents' insufficient or fragmented sleep may negatively impact   work attendance  decreased mood marital satisfaction harm parental functioning   family dynamic 

The Link between Parent and Child Sleep Disturbances in Children with ADHD Objective: Although sleep problems are widely known to be a prominent feature of childhood, little is known about the link between these difficulties and parental sleep disturbances. Methods: Data was obtained retrospectively from patient files attending attention deficit/hyperactivity disorder (ADHD) clinic. 64 ADHD diagnosed children and their parents completed measures of ADHD symptoms, sleep, anxiety and executive functioning.

Results Significant differences in parental sleep were found between children with and without clinical sleep problems. Regression analysis revealed that child pre-sleep arousal significantly predicted parental sleep. Children with a clinical sleep score were more impaired in behavioral, emotional, and cognitive domains. Finally, medicated children had lower rate of clinical sleep problems.

Summary Parental sleep was associated with child sleep difficulties and the level of pre-sleep arousal Parental sleep of children with higher level of sleep difficulties and higher arousal at bedtime was more impaired From a behavioral perspective, the hyperarousal at night time causes interruptions to bedtime routines and requires parental attendance, which may inevitably interrupt parents' sleep Children with higher levels of Adhd exhibited more sleep problems In our study, 69% of children were found to suffer from clinically sleep problems

Why to treat? The possible beneficial effects of sleep disorders treatment on ADHD core symptoms remain elusive: It has been speculated that improving sleep patterns would decrease ADHD symptoms severity but this has not yet been definitely proven. Weiss MD, Wasdell MB, Bomben MM, et al. J Am Acad Child Adolesc Psychiatry 2006;45:512–19 Is it possible that improving children sleep, we could also improve parental sleep and functioning.

Treatment of Behaviorally Based Insomnia (here “insomnia” refers to sleep-onset association and limit-setting disorders) Parent-based intervention: Sleep hygiene Behavioral intervention Sleep diary Follow up

Conclusion The key to the management of sleep problems in attention- deficit/hyperactivity disorder (ADHD) is an appropriate differential diagnosis, followed by a specific treatment of the underlying condition(s), including: behaviorally based sleep disorders Non behavioral conditions Sleep disturbances due to comorbid psychiatric disorders or ADHD medications Healthy sleep practices are the foundation of management strategies. Behavioral interventions should be the first-line treatment of insomnia.